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Dying after Discharge
Abstract & Commentary
By John Shufeldt, MD, JD, MBA, FACEP, Chief Executive Officer, NextCare, Inc.; Attending Physician/Vice Chair, Department of Emergency Medicine, St. Joseph's Hospital and Medical Center, Mesa, AZ, is Editor for Urgent Care Alert.
Synopsis: Evaluates the cause of unanticipated death in patients sent home from the emergency department in the hopes of evaluating patterns of potential preventable medical error.
Source: Sklar DP, et al. Unanticipated death after discharge home from the emergency department. Ann Emerg Med. 2007;49:735-745.
Emergency departments are considered a high-risk area for medical errors leading to patient deaths. Patients treated in the ED, who subsequently die, may be victims of medical error. This study looks at the frequency and cause of unanticipated death among patients discharged from the emergency department, and reviews the records to determine potential patterns of preventable medical error.
Previous research on patients treated and released from the ED demonstrates that 13 per 100,000 died after discharge and 3 per 100,000 suffered an unexpected death directly related to the ED visit. In this study, Man and colleagues only used the medical examiner's report to determine the incidence of death after ED visit. Ruptured aortic aneurysm was the most common cause of death in this population.
This was a retrospective 10-year study of 387,334 ED visits among 186,859 individuals in an urban tertiary-care center. Patients were included in the study if they were over 10-years-old and registered as emergency department patients in the time period from November 1994 to November 2004; dying within 7 days of discharge. Also, their death must have been reported to the Office of the Medical Examiner. Deaths were assessed for relatedness to the last ED visit to determine if the death was expected, as well as to determine if there was preventable medical error. Medical error was defined using he Institute of Medicine's definition, in which the error is "the failure of a planned action to be completed as intended (ie, error of execution) of the use of a wrong plan to achieve an aim (ie, error of planning)." The definition was further expanded to include failure to solicit or interpret information that would have led to a different action.
During the study years, there were 387,334 visits among 186,859 patients, averaging 2.1 visits per person. Half the patients were male, and the average age was 39.7 years. The average number of days between discharge from the ED to death was 3.8. Man et al identified 117 patients, or 30.2 per 100,000 ED patients, who died within 7 days of discharge. Of these 117 patients, 58 (50%) were expected and 35 (60%) had possible error. The unexpected, but related group, contained 15 patient deaths, 9 of which were determined to be caused by possible error. The mean age of the expected death group was 56.2 years; the mean ages of the possible error unexpected and nonerror unexpected was approximately 48-years-old.
Of the patients who died, 4 distinct themes emerged: atypical presentation of an acute problem, chronic disease with decompensation, abnormal vital signs, and mental illness or substance abuse that may have made it less likely that the patient would return with worse symptoms. Every patient who died had at least one of these distinct themes as a contributing cause of their death, and many of them had more than 2. Abnormal vital signs occurred in the majority (83%) of patients who died within 7 days of ED discharge.
Diagnoses for the possible error group included:
The remaining deaths were caused by a variety of different illnesses, including AIDS, sepsis, ARDS, and one missed complication from a feeing tube placement.
The risk of death post urgent care visit is not dissimilar from the risk of death post emergency department visit, in as much as patients do not necessarily self-triage appropriately. Thus, this study has broad and concerning implications for urgent care medicine.
Unexplained and unresolved abnormal vital signs, most commonly tachycardia, occurred often in cases of unexpected death. Unexplained tachycardia often occurs in ED patients as well who are discharged and do not die. Therefore, abnormal vitals are a sensitive, yet non-specific, indicator of risk. The presence of abnormal vitals should elicit some investigation, or at minimum, an explanation in the medical record.
Another common finding was the unexpected death secondary to a chronic condition, most often congestive heart failure. Man et al surmised that this may be secondary to the difficulty in discerning the steady state of a chronic condition from an insidious decompensation. In many of these patients, the discharge diagnosis was similar to the cause of death. Only the rapidity of the outcome, as opposed to the diagnosis, was at issue.
The third most common area of risk was the subtle presentation of a rare condition. ED physicians are trained to think "worst first." It is this training that hopefully improves the diagnosis of these "zebras." In an urgent care setting, the provider must be vigilant to not "drop their guard" while wading through the sea of the walking well. The diagnosis of these high-risk, low-prevalence diseases will continue to be the "holy grail" of urgent care risk reduction.
Finally, and probably less important in the urgent care setting, are the patients with mental illness who become lost to follow-up, secondary to their inability to seek further treatment if they are not getting better. In this study, many of these patients had drug or alcohol issues impeding their ability to fend for themselves.
The take home point for urgent care providers is to stay on guard for the high-risk, low-prevalence disease states, respond to abnormal vital signs, document informed consent discussions with patients and their families, and finally, to have a low threshold for transferring patients to the emergency department for continued care and diagnosis.